Alkaline Gourmet Evaluation Form

1
Name* This field is required.
First Name
Last Name
2
Best Contact Number* This field is required.
Area Code
Phone Number
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
Best Email Address* This field is required.
example@example.com
Confirm Email
5
Do you want to schedule a Consultation?* This field is required.There is an hourly fee for our consultations of $275.00 Payment for the consultation is at the end of this form if you select "Yes".
YESNO
6
Select the best time for us to meet?* This field is required.$275 Hour
7
Agree to terms of use and privacy policy* This field is required.
8
Your height:* This field is required.
9
Your weight:* This field is required.
10
Do you suffer from any of the below?Choose best answer.
YesNo
YesNo
YesNo
Dizziness
Sinuses
High Blood Pressure
Dizziness
YesNo
YesNo
YesNo
1 of 3
11
Are you a diabetic?* This field is required.
YESNO
12
What type?* This field is required.
Type 1
Type 2
13
Please provide as much info as possible to aid in your well-being.* This field is required.
Please list any allergies you have.
Please list any surgeries you have had.
Please list any medications you are currently taking.
14
Number of daily bowel movements?* This field is required.
15
List area(s) of most concern.* This field is required.
16
Do you prefer tea or capsules for detox?* This field is required.
Tea
Combo (tea and capsules)
17
Consultation Payment* This field is required.Select the consultation option you want by clicking on item below. After hitting submit you will be taken to checkout.
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Alkatrician Detox ConsultationHourly rate for consultation with the Alkatrician.
$275.00+Edit
Back
Total cost $0.00
Should be Empty: